SUMMARY.
Everyone wants to avoid surprise bills. And the “No Surprises Act,” which went into effect January 1, 2022, does not apply to excepted benefits such as stand-alone dental and vision plans.[i] The “No Surprises Act” (NSA) primarily applies to fully insured and self-funded medical plans, including grandfathered plans.[ii] So, how do members help avoid a surprise dental bill? It’s simple: A predetermination.
WHAT IS A PREDETERMINATION?
A predetermination helps members understand what their out-of-pocket expense may be prior to starting a major treatment plan. In essence, a predetermination is an estimate provided by the insurance carrier for a covered procedure. It gives a breakdown of what the insurance company will pay toward any covered service and what the member will be responsible to pay. This can help a member budget and avoid a surprise bill.
WHEN IS A PREDETERMINATION NECESSARY?
It’s a good idea to request a predetermination from an insurance company prior to receiving any major dental work. Major dental work is generally defined as anything $250 and above, although every insurer may have a different dollar threshold. In any case, a predetermination can give a member the piece of mind of knowing what to expect.
HOW MUCH TIME DOES IT TAKE?
The turnaround time on receiving a predetermination varies by carrier; however, a good rule of thumb is probably 2 – 4 weeks. The clock starts when the insurance company receives all the necessary information from a dentist on a member’s treatment plan, which includes dental records, radiographs, etc. The process can take longer if the insurer needs to request additional information from a member’s dentist.
DOES A PREDETERMINATION EXPIRE?
Most dental predeterminations are valid for one year, but check with your individual carrier to verify their expiration policies. In many cases, the expiration date is printed directly on the predetermination form.
USING A PREDETERMINATION AS A SECOND OPINION.
BeneCare often recommends that its members request a predetermination as a way to get a second opinion.[iii] Our in-house dental consultants are licensed dentists with years of experience in a clinical setting. One of our consultants reviews each predetermination to ensure the suggested treatment plan meets the community standard for necessity, appropriateness, and effectiveness. This review process can essentially act as second opinion for the suggested treatment plan.
THE BOTTOM LINE.
Requesting a predetermination from the insurance carrier prior to proceeding with any major dental work can help you avoid a surprise bill and help you budget for any necessary treatment.
NEED MORE INFORMATION?
Members with questions can call our Client Services team at 800.843.4727. Plan sponsors should contact their benefit consultant for additional details or contact us directly using an online request or by calling 800.445.6665. Benefit Consultants may also call 800.445.6665 or submit an online request.
[i] Beth Fuchs and Jack Hoadley, “Summary of the No Surprises Act (H.R. 133, P.L. 116-260),” The Commonwealth Fund, January 11, 2021 (Updated January 19, 2021), https://www.commonwealthfund.org/sites/default/files/2021-01/Surprise_Billing_Law_Summary_v2_UPDATED_01-19-2021.pdf, accessed February 9, 2022.
[ii] Milanna Datlow, “Implementing Regulations for The No Surprises Act: Part I,” The Roffe Group of Robertson + Cole, August 9, 2021, https://www.erisaclaimdefense.com/implementing-regulations-for-the-no-surprises-act-part-i/, accessed on February 9, 2022.
[iii] Predeterminations are not a guarantee of payment. They are based on the eligibility and benefit information in force at the time they are prepared. Actual payment is based on eligibility and benefit information in force at the time of claim submission, which may differ. Interim treatment may also affect final benefit determination.
